Prescription patterns relevant to young people with epilepsy of childbearing potential.

RATIONALE: Young people with epilepsy of childbearing potential (YPWECP) are vulnerable to a variety of adverse health outcomes due to teratogenic antiseizure medications (ASMs) and drug-drug interactions between ASMs and contraceptives that can lead to breakthrough seizures and/or contraceptive failure. To better understand reproductive healthcare provision for YPWECP, we conducted a retrospective analysis of relevant prescription patterns. METHODS: We analyzed procedural and medication data for YPWECP ages 13-21 years (n = 1525) from 2011 through 2021 at a single tertiary-care pediatric medical center to investigate rates of (1) prescription of folic acid, (2) prescription of an enzyme-inducing ASM<6 months before or after hormonal contraception initiation (or < 3 years after subdermal implant placement), (3) prescription of lamotrigine < 6 months before or after an estrogen-containing contraceptive that could affect lamotrigine serum concentrations, and (4) documentation of any contraceptive medication or device that overlaps initiation of a patient's first teratogenic ASM. We performed statistical analyses with sample proportion z-tests. We then used logistic regression and generalized estimating equations to evaluate for associations between patient characteristics and prescription patterns. RESULTS: Among 1525 YPWECP, less than half (41 %, n = 629) were prescribed folic acid during the study period (95 % CI 38.8-43.7). Of YPWECP prescribed an enzyme-inducing ASM, 24 % (186/766) were co-prescribed a hormonal contraceptive that adversely interacts with the ASM (95 % CI 21.2-27.3 %). Of those prescribed lamotrigine during the study period, 24 % (111/472) had documentation of an estrogen-containing medication that could affect lamotrigine serum concentrations < 6 months before or after that prescription (95 % CI 19.7-27.3 %). Of those prescribed a teratogenic ASM, only 13 % (82/638) had documentation of contraception prior to (or within the same month as) starting their first teratogenic ASM (95 % CI 10.3-15.5 %). Older age was associated with increased odds of contraceptive coverage prior to initiation of the first teratogenic ASM and was also associated with increased odds of having contraceptives co-prescribed with ASMs that could interact. No significant associations were found between race/ethnicity and any outcomes. CONCLUSIONS: YPWECP experience low rates of folic acid prescription and low rates of contraceptive coverage while prescribed teratogenic ASMs. Many YPWECP, particularly older adolescents, are at increased risk for contraceptive failure and/or breakthrough seizures due to drug-drug interactions. Results demonstrate a need for increased focus on reproductive healthcare for YPWECP. Future studies should evaluate interventions aimed at improving these outcomes.

Communication and Counseling Preferences of Women Who Chose Abortion During Adolescence: A Qualitative Study.

STUDY OBJECTIVE: As part of a larger study about pregnancy options counseling with adolescents, we interviewed women in the United States who chose abortion during adolescence about preferences and experiences regarding communication from healthcare professionals during abortion care. DESIGN, SETTING, AND PARTICIPANTS: We conducted individual semi-structured interviews with women ages 18-35 years old who were pregnant before age 20 years old and chose abortion. We recruited participants through social media, a research registry, and flyers in healthcare facilities. We recorded and transcribed interviews. Two investigators coded interview transcripts using thematic analysis. RESULTS: We conducted interviews with 17 US women (median age 32 years old, range 20-35 years old) from 11/2020-4/2021. The median age at time of abortion was 18 years old (range 14-19 years). The sample was 58% (n = 10) Caucasian and 65% (n = 11) heterosexual. Themes included: 1) Participants perceived options counseling before abortion as important and necessary but did not always feel they personally needed it. 2) Participants reported that clinicians including nurses, physicians, and other staff sometimes had poor bedside manner, which was not aligned with their perceived need for gentleness due to their adolescence. 3) Participants valued nonjudgmental communication including normalization of abortion care. 4) Participants desired privacy and confidentiality throughout their clinic appointment, but clinic logistics led to concerns about limited privacy. 5) Participants appreciated medically accurate information about abortion in plain language balancing safety and risk information for reducing fear before the procedure. CONCLUSION: Responses suggested specific best practices that healthcare providers can adopt to improve care for youth considering abortion.

Use of Natural Language Processing to Identify Sexual and Reproductive Health Information in Clinical Text.

OBJECTIVES: This study aimed to enable clinical researchers without expertise in natural language processing (NLP) to extract and analyze information about sexual and reproductive health (SRH), or other sensitive health topics, from large sets of clinical notes. METHODS: (1) We retrieved text from the electronic health record as individual notes. (2) We segmented notes into sentences using one of scispaCy's NLP toolkits. (3) We exported sentences to the labeling application Watchful and annotated subsets of these as relevant or irrelevant to various SRH categories by applying a combination of regular expressions and manual annotation. (4) The labeled sentences served as training data to create machine learning models for classifying text; specifically, we used spaCy's default text classification ensemble, comprising a bag-of-words model and a neural network with attention. (5) We applied each model to unlabeled sentences to identify additional references to SRH with novel relevant vocabulary. We used this information and repeated steps 3 to 5 iteratively until the models identified no new relevant sentences for each topic. Finally, we aggregated the labeled data for analysis. RESULTS: This methodology was applied to 3,663 Child Neurology notes for 971 female patients. Our search focused on six SRH categories. We validated the approach using two subject matter experts, who independently labeled a sample of 400 sentences. Cohen's kappa values were calculated for each category between the reviewers (menstruation: 1, sexual activity: 0.9499, contraception: 0.9887, folic acid: 1, teratogens: 0.8864, pregnancy: 0.9499). After removing the sentences on which reviewers did not agree, we compared the reviewers' labels to those produced via our methodology, again using Cohen's kappa (menstruation: 1, sexual activity: 1, contraception: 0.9885, folic acid: 1, teratogens: 0.9841, pregnancy: 0.9871). CONCLUSION: Our methodology is reproducible, enables analysis of large amounts of text, and has produced results that are highly comparable to subject matter expert manual review.

A retrospective textual analysis of sexual and reproductive health counseling for adolescent and young adult people with epilepsy of gestational capacity.

Rationale The American Academy of Neurology (AAN) recommends annual sexual and reproductive health (SRH) counseling for all people with epilepsy of gestational capacity (PWEGC). Child neurologists report discussing SRH concerns infrequently with adolescents. Limited research exists regarding documentation of such counseling. METHODS: We retrospectively studied clinical notes using natural language processing to investigate child neurologists' documentation of SRH counseling for adolescent and young adult PWEGC. We segmented notes into sentences and evaluated for references to menstruation, sexual activity, contraception, folic acid, teratogens, and pregnancy. We developed training sets in a labeling application and used machine learning to identify additional counseling instances. We repeated this iteratively until we identified no new relevant sentences. We validated results using external reviewers; after removing sentences reviewers disagreed on (n = 13/400), we calculated Cohen's kappa values between the model and reviewers (>0.98 for all categories). We evaluated labeled texts for each patient per calendar year with descriptive statistics and logistic regression, adjusting for race/ethnicity, age, and teratogen use. RESULTS: Data comprised 971 PWEGC age 13-21 years with 2277 patient-years and 3663 outpatient child neurology notes. Nearly half of patient-years lacked SRH counseling documentation (49.1%). Among all patients, 38.0% never had SRH counseling documented. Documentation was present regarding menstruation in 26.7% of patient-years, folic acid in 25.0%, contraception in 21.9%, pregnancy in 3.5%, teratogens in 3.0%, and sexual activity in 1.8%. Documentation regarding menstruation and contraception was associated with prescription of antiseizure medications that have a higher risk of teratogenic effects (OR = 1.27, p = 0.020, 95% CI = [1.04,1.54]; OR = 1.27, p = 0.027, 95% CI = [1.03,1.58]). Documentation regarding contraception, folic acid, and sexual activity was increased among older patients (OR = 1.28, p < 0.001, 95% CI = [1.21,1.35]; OR = 1.26, p < 0.001, 95% CI = [1.19,1.32]; OR = 1.26, p = 0.004, 95% CI = [1.08,1.47]). Documentation regarding sexual activity was decreased among patients identifying as White/Non-Hispanic (OR = 0.39, p = 0.007, 95% CI = [0.20,0.78]). CONCLUSION: Child neurologists counsel PWEGC on SRH less frequently than recommended by the AAN based on documentation.